November 2017 Imaging Case of the Month

Michael B. Gotway, MD¹

Isabel Mira-Avendano, MD²

¹Mayo Clinic Arizona, Scottsdale AZ USA

²Mayo Clinic Jacksonville, FL USA

Clinical History: A 70-year-old white woman with a remote history of smoking and mild gastroesophageal reflux disease presented with complaints of a dry cough and shortness of breath, present for some time but worsening over the previous 8 months. No hemoptysis was noted and the patient did not complain of chest pain. No history of syncope was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 86% on room air, 90% on 4 L/m by mask. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Enhanced thoracic CT (Figure 1) was performed.

Figure 1. Panels A-D: Representative static images from the thoracic CT scan in lung windows. Lower panel: Video of thoracic CT scan in lung windows.

Which of the following statements regarding the thoracic CT is most accurate? (Click on the correct answer to proceed to the second of eight pages)

1. The thoracic CT shows advanced destructive emphysema
2. The thoracic CT shows bilateral, basal and subpleural predominant reticulation associated with ground-glass opacity, architectural distortion, and traction bronchiectasis
3. The thoracic CT shows multifocal lobular consolidation
4. The thoracic CT shows multifocal small pulmonary cysts
5. The thoracic CT shows small cavitary pulmonary nodules

Cite as: Gotway MB, Mira-Avendano I. November 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(5):199-208. doi: https://doi.org/10.13175/swjpcc134-17 PDF

Medical Image of the Week: Scleroderma

Figure 1. Frontal view of the chest shows shallow lung volumes with reticulation and bronchiolar dilatation, including slightly asymmetric basilar opacity, left greater than right most suggestive of interstitial lung disease.

Figure 2. X-ray of the right hand performed 2 years prior to the chest x-ray reveals distal tuft resorption and erosions in addition to distal subcutaneous calcifications. The finger tips also appear atrophied and tapered.

A 56-year-old man presents with cough and dyspnea. Pertinent history is significant for scleroderma. A complete blood count and differential count were unremarkable. A chest radiograph was obtained (Figure 1). Based on overall imaging and clinical history, the chest x-ray findings are highly suggest interstitial lung disease likely related to scleroderma and a recommendation for high resolution chest CT was made.

Progressive systemic sclerosis (scleroderma) is an autoimmune connective tissue disease that affects 30-50 year old women more often than men and is characterized by the overproduction of collagen which can lead to fibrosis which includes the lungs, skin, and may also affect visceral organs (1). In the hands, vasculitis and Raynaud's phenomenon may lead to distal tapering (2). Although acro-osteolysis or distal tuft resorption can be seen in a wide variety of disorders, it may be present in up to 80% of patients with scleroderma. High-resolution chest CT is helpful to characterize the degree of involvement and fibrosis which tends to be basilar and peripherally predominant and may include both usual interstitial pneumonia or nonspecific interstitial pneumonitis as common patterns.

Veronica A. Arteaga MD and Kenneth S. Knox MD

Departments of Medical Imaging and Pulmonary and Critical Care

University of Arizona Medical Center

Tucson, Arizona

References

1. Mayberry JP, Primack SL, Müller NL. Thoracic manifestations of systemic autoimmune diseases: radiographic and high-resolution CT findings. Radiographics. 2000;20(6):1623-35. [CrossRef] [PubMed]
2. Manaster BJ, May DA, Disler DG. Musculoskeletal Imaging, The Requisites, 4^th edition. Mosby, Elsevier. Chapter 20: Connective Tissue Disorders, pages 288-293.

Reference as: Arteaga VA, Knox KS. Medical image of the week: scleroderma. Southwest J Pulm Crit Care. 2015;10(4):199-200. doi: http://dx.doi.org/10.13175/swjpcc034-15 PDF

Medical Image of the Week: CREST plus ILD

Figure 1. Illustrations of CREST syndrome (see below).

A 60 year old female with a history of fibromyalgia presented with dyspnea and skin changes, predominantly on the hands.  Physical exam and imaging showed classic findings of limited cutaneous systemic sclerosis (scleroderma) CREST syndrome.  Calcinosis cutis (Figure 1A), Raynaud’s (not shown but endorsed by the patient), Esophageal dysmotility (Figure 1B, dilated esophagus), Sclerodactyly (Figure 1C), and Teleganectasias (Figure 1D) were all present.  Ground glass opacities were seen predominantly in the bilateral lower lung zones, associated with increased reticular markings (Figure 2A), and traction bronchiectasis (Figure 2B). 

Figure 2. Representative images from the patient’s CT scan showing pulmonary involvement.

Pulmonary involvement is noted in the majority of scleroderma patients.  Interstitial lung disease (ILD) is common and often portends a poor prognosis.

Isabel Oliva, MD and Ken Knox, MD

Division of Thoracic Imaging and Pulmonary & Critical Care Medicine

Interstitial Lung Disease Program

Reference as: Oliva I, Knox K. Medical image of the week: CREST plus ILD. Southwest J Pulm Crit Care. 2013;6(6):275-6. PDF